Facial nerve anastomosis in the mastoid portion using a cable graft. Case report

We describe a case of a 52-year-old woman in whom surgery for two tumours located in the cerebellar hemisphere and in the posterior petrous bone was complicated by interruption of the facial nerve (CN VII). During the same procedure, anastomosis of CN VII, using a cable graft harvested from the great auricular nerve, was performed. Seven months later the first signs of reinnervation of the facial muscles were noticed. Two and a half years after surgery, CN VII function was assessed as grade II/III according to the House-Brackmann scale. The authors emphasize the significance of immediate repair of CN VII in modern skull base surgery but also the importance of a patient's self-training to obtain the best functional outcome of the facial reanimation. Reconstruction using the great auricular nerve has two significant advantages: first, the patient avoids further procedures for nerve repair, and second, the harvested nerve is located in direct proximity to the operation area.     

Facial nerve damage following surgery for cerebellopontine angle tumours. Prevention and comprehensive treatment

Facial nerve (CN VII) palsy or even its transient paresis causes physical disability but is also a psychosocial problem. Immediately after vestibular schwannoma removal, different degrees of CN VII paresis occur in 20-70% of patients. Facial nerve paresis is observed in 10-40% after surgery of cerebellopontine angle meningiomas. Postoperative facial nerve weakness significantly reduces or completely withdraws with time in the majority of cases. However, even if prognosis for CN VII regeneration is good, proper management is needed because of the potential for serious ophthalmic complications. In this paper, the authors raise the issue of perioperative prophylaxis and comprehensive treatment of postoperative paresis of CN VII. Prophylaxis and treatment of ophthalmic complications are discussed. Current trends in the treatment of intraoperative loss of facial nerve continuity, management of facial paresis with good prognosis and dealing with facial palsy with no spontaneous recovery are also described in the paper.     

Motoneurons innervating facial muscles after hypoglossal and hemihypoglossal-facial nerve anastomosis in rats

Hypoglossal-facial nerve anastomosis (HFA) is the most popular surgical procedure to reinnervate facial muscles after injury of the facial nerve. Section of the hypoglossus causes paralysis and atrophy of the hemi-tongue. In the attempt to overcome this consequence, the hemihypoglossal-facial nerve anastomosis (HHFA) has been proposed and only a half of the main trunk of the hypoglossus is connected to the distal stump of the facial nerve. In the rat, we have studied experimentally the anatomical nuclear changes after HFA and HHFA with the aim of establishing the quantitative motoneuron innervation of facial muscles obtained with each one of the two operative options. Horseradish peroxidase (HRP) injected in both types of anastomosis labeled not only hypoglossal motoneurons, but also facial motoneurons. HFA appeared to offer a significant quantitative motoneuron innervation higher than HHFA and then a higher probable better functional recovery. Both HFA and HHFA performed immediately after section of the facial nerve in rats did not result in a phenomenon of motor hyperinnervation. In our experimental model, the proximal facial nerve stump was coagulated at the stylomastoid foramen to avoid regeneration. Then, the labeled motoneurons into the facial nucleus could really be the expression of axonal projections from facial motoneurons to the hypoglossus nerve and facial muscles. No labeled motoneurons were seen contralaterally as we observed previously after section and repair of several nerves.     

Hypoglossal nerve palsy: 245 cases

Introduction: Apart from a case series of 100 subjects in 1996 and several small cohorts, there have been no large retrospective series of cranial nerve XII (CN XII) palsy. Methods: From 1984 to 2014, 245 cases of CN XII palsy were identified via retrospective chart review using historical and exam findings that confirmed the diagnosis. In addition to clinical characteristics, univariate and multivariate models were investigated to predict neoplastic CN XII palsy. Results: Major etiologic categories included: postoperative (29.3%), idiopathic (15.1%), primary neoplastic (14.2%), metastatic malignancy (13.0%), inflammatory (7.3%), radiation (6.1%), and traumatic (4.1%). A multivariate model revealed male gender and a personal history of cancer as predictive of neoplastic CN XII palsy. Conclusions: The most frequent etiologies and disease categories of CN XII palsy were identified, and male gender and personal history of cancer were found to be predictive of a neoplastic cause of CN XII palsy. Muscle Nerve 54 : 1050–1054, 2016     

Unilateral hypoglossal nerve palsy due to neurovascular conflict in a child

A neurovascular conflict (NC) consists of a pathological contact between a vessel, generally an artery, and the root entry zone of a cranial nerve close to the brainstem. Even if NC of the V, VII and IX cranial nerve have been rarely described, to the best of our knowledge there is no report about the XII cranial nerve NC in the paediatric age. A three-year-old girl presented with right-sided tongue atrophy and fasciculation, of one-year-duration, consistent with a peripheral lesion of the right XII cranial nerve. Brain MRI and MRA documented a marked tortuosity of the vertebrobasilar arteries compressing the brainstem at the emergency of the XII cranial nerve, while the CT disclosed a concomitant osseous malformation of the cranio-cervical junction. The differential diagnosis of a peripheral unilateral cranial nerve palsy should include, even if rare in children, a neurovascular conflict. In this case a complete neuroimaging study is indicated.     

Quantitative ultrasonography of facial muscles in patients with chronic facial palsy

Introduction: In this study we introduce quantitative facial muscle ultrasound as a diagnostic tool for patients with chronic unilateral facial palsy. Methods: Muscle area, thickness, and echo intensity of 6 facial muscles (frontalis, orbicularis oculi, orbicularis oris, depressor anguli oris, depressor labii inferioris, and mentalis) and of 2 chewing muscles (temporalis and masseter, as controls) were measured in 20 patients with chronic facial palsy. Results: Aside from 1, all facial muscles were significantly smaller on the paralyzed side. With exception of frontalis and orbicularis oculi muscles, all other facial muscles showed significantly higher echo intensity on the affected side. Muscle size and echo intensity of the chewing muscles showed no side‐to‐side asymmetry. Conclusions: Quantitative ultrasound of facial muscles helps to better characterize their status in patients with chronic facial palsy in the phase of denervation and during regeneration. Muscle Nerve 50 : 358–365, 2014     

Delayed hypoglossal-facial nerve suture after predegeneration of the peripheral facial nerve stump improves the innervation of mimetic musculature by hypoglossal motoneurons

Surgical reconstruction of the facial nerve is common clinical practice following destruction of the intracranial facial nerve. Delayed hypoglossal-facial anastomosis (HFA) is the procedure of choice, although the effect of delay on outcome remains unclear. To study the effect of delayed anastomosis on reinnervation, we sutured the proximal stump of a freshly transected hypoglossal nerve of Wistar rats to the distal stump of the ipsilateral facial nerve, which had been transected 7–56 days earlier. Animals that had received HFA without delay served as the control group. Forty days after HFA, horseradish peroxidase (HRP) was injected into the whisker pad; 2 days later, the animals were killed. Reinnervation was assessed by determining the proportion of labeled neuronal cell bodies in the brainstem. The control group had 68% reinnervation of these muscles by hypoglossal neurons and had 32% reinnervation by facial neurons. When the distal facial nerve had been allowed to degenerate for 7 days before HFA, reinnervation of the hypoglossal nerve decreased to 54%, and reinnervation by the facial nerve increased to 46%. However, after a delay of 10–56 days, the hypoglossal fraction increased and stabilized at 77%, and the facial motoneuron fraction decreased to 23%. The presence of new neuromuscular junctions was confirmed by HRP labeling of motor end plates in vivo and by electromyography. We conclude that, under the conditions of hypoglossal-facial crossed nerve suture, the predegeneration of the distal stump of a transected facial nerve enhances the reinnervation of facial muscles by hypoglossal axonal sprouts. J. Comp. Neurol. 387:234–242, 1997. © 1997 Wiley-Liss, Inc.     

Progressive hemifacial atrophy with localized scleroderma

We describe a patient with localized scleroderma in association with homolateral atrophy of the tongue and marked ipsilateral facial hemiatrophy which was confirmed histologically. CT scan coronal sections of the face showed severe atrophy of the tongue and facial muscles. The EMG studies failed to demonstrate a neurogenic or myogenic process.     

周围性面瘫的手术治疗浅析

周围性面瘫是临床上常见的一种疾病,大多数经过内科治疗是可以治愈的,但对于少数内科治疗效果不佳者,最终尚需手术治疗。由于病因、病程等不同,手术时机、方式等尚有进一步探讨的必要。我们通过对不同病因、不同病程的4例患者进行了手术治疗,效果满意。通过我们的操作体会认为面神经吻合术为早期外伤性面瘫治疗的最佳选择,阔筋膜静态悬吊术对于晚期面瘫病例可改善部分症状,为恢复面瘫静态外观的有效方法,不失为可供选择的术式。     

A case of unilateral lingual atrophy and ipsilateral muscular atrophy supplied by trigeminal nerve--in relation to progressive facial hemiatrophy]

A 39-year-old man was admitted to our hospital because of atrophy of the right side of the tongue of 6 years' duration. Neurological examination showed atrophy and fasciculations in the right side of the tongue. Magnetic resonance imaging showed atrophy and high signal intensity areas on T1 and T2 weighted images in the right masseter, temporal, lateral and medial pterygoid muscles. Electromyography showed fibrillations and positive sharp waves at rest, high amplitude polyphasic motor unit potentials with weak contraction in the right tongue and masseter muscles. Examination of autonomic functions suggested postganglionic lesion of right facial sympathetic nerves. We believe that this case may be related to progressive facial hemiatrophy.     

Effects of hypoglossal and facial nerve injuries on milk-suckling

Functional roles of the perioral anatomical structures involved in breastfeeding were examined in newborn rat pups in which the hypoglossal (XII) and facial (VII) nerves had been resected at the neonatal stage. The XII nerve controls tongue movement and is comprised of two functionally distinct branches: the medial branch related to protrusion of the tongue and the lateral branch related to its retraction. Newborn rat pups with bilateral resection of either of the XII nerve components (main trunk: XII-trunk; medial branch: XII-med; lateral branch: XII-lat) failed to suckle milk and did not survive. Unilateral XII nerve-resected neonates showed different milk-suckling capabilities, which thus resulted in differences in survival rate (XII-trunk: 38%; XII-med: 24%; XII-lat: 92%) and postnatal growth during the postnatal 3 weeks until P21. Unilateral and bilateral resections of the VII nerve innervating the buccolabial musculature produced lowered suckling capabilities and retarded postnatal growth, although all pups showed 100% survival. The results indicate a crucial role of the tongue, especially of protruding muscular elements innervated by the XII-med nerve, in breastfeeding. The results also indicate differential effects of the VII and XII nerve components on suckling capability, survival, and postnatal growth of newborn rat pups.     

Early and continued manual stimulation is required for long‐term recovery after facial nerve injury

Introduction: We previously have shown that manual stimulation (MS) of vibrissal muscles for 2 months after facial nerve injury in rats improves whisking and reduces motor end plate polyinnervation. Here, we seek to determine whether discontinuing or delaying MS after facial–facial anastomosis (FFA) leads to similar results. Methods: Rats were subjected to FFA and received MS for (1) 4 months (early and continued), (2) the first but not the last 2 months (discontinued), or (3) the last 2 months (delayed). Intact animals and those not receiving MS (no MS) were also examined. Results: Early and continued MS restored whisking amplitude to 43°, a value significantly higher compared with the discontinued, delayed, and no MS groups (32°, 24°, and 10°, respectively). Motor end plate polyinnervation occurred in all experimental groups but was significantly higher in the delayed group. Discussion: Early and continued MS results in better recovery than when it is either discontinued or delayed. Muscle Nerve 57 : 100–106, 2018     

Related timing for peripheral and central plasticity in hypoglossal-facial nerve anastomosis

The aim of this work was to determine the role of peripheral facial muscle reinnervation in the central reorganization of the blink reflex (BR) after hypoglossal-facial anastomosis (HFA). An electrophysiological study was performed on seven patients who underwent HFA after facial nerve transection during surgery for acoustic neuroma. HFA was performed within 15 days after surgery in five patients (group 1) and later for the two others (group 2). We studied the motor responses (MR) and the BR evoked on the affected side, before and over 3 years after the HFA. The MR appeared by the third month for the first group, and by the sixth and twelfth for the second group. After 36 months, the amplitude of MR was significantly higher than its control value, showing hyperinnervation of the facial muscles. Study of the BR evoked only an R1-type blink response that was observed 4 and 6 months after the MR for groups 1 and 2, respectively. This central reorganization appeared closely correlated with muscle reinnervation and its related timing. The occurrence of peripheral nerve-muscle contacts seems to be a necessary condition for reorganization of the trigemino-hypoglossal-facial reflex.     

低水平神经肌肉阻滞状态下听神经瘤切除术中面神经的保护

目的在低水平神经肌肉阻滞状态下进行听神经瘤切除术中面神经的保护。方法28例大、中型听神经瘤患者行听神经瘤切除术,术中应用AXONEpochXP神经电生理工作站,根据4个成串刺激(train of four stim-ulation,TOF)和脑电图(EEG)分别监测肌松程度和麻醉深度,在肿瘤切除过程中通过调节肌松药物和麻醉药物剂量使T4/T1维持在25%～50%,术中监测眼轮匝肌、口轮匝肌、咬肌和斜方肌自由描记肌电图和诱发肌电图,分别反应面神经、三叉神经和副神经功能。于术后1周和术后第6个月分别评估面神经功能。结果28例患者术中均成功探测到面神经走行,电刺激强度为0.1～0.3mA,术中无患者发生体动情况。术后面神经功能保留率良好,术后1周面神经House-Brackmann(H-B)功能分级为Ⅰ级者5例、Ⅱ级者13例,Ⅲ级者8例,Ⅳ级者2例;至术后6个月面神经H-B功能分级Ⅰ级者10例,Ⅱ级者12例,Ⅲ级者5例,Ⅳ级者1例。结论在听神经瘤手术过程中通过电生理监测对面神经进行保护,需要电生理、麻醉和手术医生的配合。在低水平神经肌肉接头阻滞状态下,完全可以达到确保手术安全进行及保护面神经功能的目的。     

Electrodiagnostic studies of the facial nerve in peripheral facial palsy and hemifacial spasm

Electrodiagnostic (EDX) assessment is one of the most important aspects in the evaluation of the two most common disorders of the facial nerve: facial palsy and hemifacial spasm. Facial palsy is usually an acute disorder that resolves in a few weeks but, in a number of cases, leads to a postparalytic facial syndrome featuring muscle synkinesis, myokymia, and involuntary mass contractions of muscles on the affected side. Hemifacial spasm is usually a chronic disorder characterized by paroxysms of involuntary, clonic, and synchronous twitching of all facial muscles on the affected side. EDX studies provide information on lesion location and severity, pathophysiology underlying the two disorders, and differential diagnosis between syndromes presenting with abnormal facial muscle activity. This monograph is intended to describe the most relevant EDX findings in the two disorders and the most appropriate timing for the examinations in order to provide useful information for prognosis and therapeutic decision-making.     

Myokymic discharges and enhanced facial nerve reflex responses after recovery from idiopathic facial palsy.

A functional disorder of facial muscle activity commonly occurs in patients after recovery from Bell's palsy with axonal degeneration. The postparalytic facial dysfunction is probably related to the aberrant growing of regenerating axons, although other theories such as ephaptic transmission, spontaneous generation of impulses, and enhancement of motoneuron excitability should also be considered. In this work, we have carried out a comparative electrophysiological study of both sides of the face in 23 patients who had recovered from a unilateral Bell's palsy with axonal degeneration. At rest, spontaneous firing of motor units was observed in muscles of the previously paralyzed side. Direct motor responses to facial nerve stimulation were smaller in the muscles of the previously paralyzed side, but reflex responses obtained in the same muscles by stimulation of either the facial or trigeminal nerve were larger when compared with those of the contralateral side. These data indicate that patients with "postparalytic facial dysfunction" may have an increased background muscle activity, as well as an enhanced recruitment of facial motoneurons to reflex activation in the side of the previous paralysis. These findings are compatible with an enhanced level of motoneuron excitability in the facial nucleus.     

High‐resolution ultrasound in the evaluation and prognosis of Bell’s palsy

Introduction: Bell’s palsy is a commonly encountered paralysis of the facial nerve occurring worldwide. Prognosis for Bell’s palsy is good, but the proportion of patients with poor outcomes may reach 30%. Ultrasound (US) may provide a novel approach for evaluating and prognosticating Bell’s palsy, in comparison with known electrophysiological techniques. Methods: In this study, we measured the diameter of the distal facial (VII) nerve using US in patients with Bell’s palsy treated with prednisolone, in comparison with healthy controls. Blink reflex and VII nerve conduction studies were also performed. Studies were prospective and performed within 1 week of disease onset. Results: Our results have shown that diameter of the distal VII nerve is a good predictor of favorable (positive predictive value: 100%) and bad outcomes (negative predictive value: 77%) in Bell’s palsy at 3 months after clinical presentation. Furthermore, we also noted the lack of correlation of VII diameter with conventional VII nerve conduction studies (NCS) and blink reflex studies. US was superior to VII nerve conduction and blink reflex studies in outcome prediction. Conclusions: This first study utilizing US in Bell’s palsy highlights its role in outcome prediction and contributes to our understanding of recovery processes in this common neurological disorder.     

The identification of neuroapraxia, axonostenosis and trigger zone in facial nerve pathology

The classical electromyographic investigations and simultaneous recordings of voluntary activity and M responses from muscles of both the upper and lower branch of the facial nerve were carried out in 5 patients with Bell's palsy. R1 responses were also recorded. All investigations were extended to the healthy side. With the aim of localizing the point of axonostenosis with axonal atrophy we investigated the following parameters: conduction velocity (c.v.) in the fallopian canal, c.v. in the external facial nerve, side difference of R1-M. In one case of amyotrophic lateral sclerosis with previous Bell's palsy signs of collateral sprouting and of ephaptic transmission were detected. This text was presented by communication at the Italo-Polish meeting held in Rome on 20–21 April 1985, arranged by the Società Italiana di Neurologia     

Outcome‐dependent coactivation of lip and tongue primary somatosensory representation following hypoglossal–facial transfer after peripheral facial palsy

A hypoglossal–facial transfer is a common surgical strategy for reanimating the face after persistent total hemifacial palsy. We were interested in how motor recovery is associated with cortical reorganization of lip and tongue representation in the primary sensorimotor cortex after the transfer. Therefore, we used functional magnetic resonance imaging (fMRI) in 13 patients who underwent a hypoglossal–facial transfer after unilateral peripheral facial palsy. To identify primary motor and somatosensory tongue and lip representation sites, we measured repetitive tongue and lip movements during fMRI. Electromyography (EMG) of the perioral muscles during tongue and lip movements and standardized evaluation of lip elevation served as outcome parameters. We found an association of cortical representation sites in the pre‐ and postcentral gyrus (decreased distance of lip and tongue representation) with symmetry of recovered lip movements (lip elevation) and coactivation of the lip during voluntary tongue movements (EMG‐activity of the lip during tongue movements). Overall, our study shows that hypoglossal–facial transfer resulted in an outcome‐dependent cortical reorganization with activation of the cortical tongue area for restituded movement of the lip. Hum Brain Mapp 35:638–645, 2014. © 2012 Wiley‐Periodicals, Inc.     

颈动脉内膜剥脱术致周围性舌下神经麻痹综合康复治疗:1例报道及文献复习

目的:周围性舌下神经麻痹的临床诊治率较低,相当一部分患者未能得到及时而正确的康复治疗。本文旨在报道颈动脉内膜剥脱术致周围性舌下神经麻痹的综合康复治疗方法及临床疗效。方法:2016年3月1日,天津医科大学总医院康复医学科收入1例颈动脉内膜剥脱术致周围性舌下神经麻痹患者,对该患者进行包括舌肌运动训练、神经肌肉电刺激疗法和远红外线治疗在内的为期15 d的综合康复治疗及口服神经营养药物治疗。回顾性分析诊治过程,并对相关文献进行复习。结果:接受综合康复治疗15 d后,舌肌较治疗前灵活,构音较治疗前清晰,吞咽时对食团的控制能力和搅拌能力均得到改善;伸舌虽然仍略向右偏斜,但舌正中沟与正中线的夹角较治疗前减少17.5°;右侧舌体表面皱褶减少,舌体饱满红润;舌尖向上可触及上嘴唇;向左舔嘴角时费力程度减轻;向右伸舌时颈部肌肉张力明显降低;向口腔内部卷曲舌尖可触及软腭边缘。康复治疗效果令人满意。结论:周围性舌下神经麻痹的康复治疗方法鲜见报道。在口服神经营养药物的基础上,同时应用舌肌运动训练、神经肌肉电刺激疗法和远红外线治疗在内的康复治疗方法,可以有效地改善患者的舌肌运动功能和舌肌萎缩程度,成为改善周围性舌下神经麻痹的安全而有效的康复治疗方法。